Fwd: Psychosis Risk Syndrome--Psychiatry's Hunting License

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ALLIANCE FOR HUMAN RESEARCH PROTECTION A Catalyst for Public Debate: Promoting Openness, Full Disclosure, andAccountability http://www.ahrp.org FYI Following the acknowledgement reported by The New York Times (Feb. 10,2010), that "Studies of teenagers identified as at high risk of developingpsychosis, for instance, find that 70 percent or more in fact do not comedown with the disorder," we wrote:"Imagine the human tragedies that follow the mislabeling of 70% of childrenas severely mentally ill, who are then exposed to extremely toxic drugs thatinduce diabetes, cardiovascular disease, and a host of other severe adverseeffects. Adding insult to injury, US taxpayers have been saddled with thecost of drugs that undermine the health of children who then requirelife-long care for drug-induced (iatrogenic) chronic diseases."http://www.ahrp.org/cms/content/view/681/9/Dr Allen Frances, the chairman of psychiatry's DSM-IV Task Force, who isprofessor emeritus at Duke University, strongly validates our alarm aboutthe DSM-V Task Force recommendations--in particular the introduction of"psychosis risk syndromes." Indeed, Dr. Frances has been highly critical ofthe DSM5 Task Force for its failure to follow fundamental professionallyvalid standards when recommending adoption of new "diagnoses.Every new diagnosis suggested for DSM5 requires (but has not yet received)a searching risk/benefit analysis and a thorough forensic review....Among all the problematic suggestions for DSM5, the proposal for a"Psychosis Risk Syndrome" stands out as the most ill--conceived andpotentially harmful. It aims to solve a pressing problem in psychiatry-- theneed for early identification and preventive treatment."He notes that the concept of early intervention rests on 3 fundamentalpillars--"being able to diagnose the right people and then providing them with atreatment that is effective and safe. "Psychosis Risk Syndrome" fails badlyon all 3 counts: 1. It would misidentify many teenagers who are not really at risk forpsychosis. 2. The treatment they would most often receive (atypical antipsychoticmedication) has no proven efficacy, but. . . 3. It does have definite dangerous complications."So, the elimination of the "bipolar" diagnosis for children, did noteliminate the mislabeling of children.Indeed, Dr. Frances forthrightly states:"DSM5 would create tens of millions of newly misidentified false positive"patients," thus greatly exacerbating the problems caused already by anoverly inclusive DSM4.[7] There would be massive overtreatment withmedications that are unnecessary, expensive, and often quite harmful. DSM5appears to be promoting what we have most feared--the inclusion of manynormal variants under the rubric of mental illness, with the result that thecore concept of "mental disorder" is greatly undermined."The impact of DSM-V on the nation's healthcare budget would simply leave nomoney for treating bone fide medical illnesses. So, maybe, just maybe, theObama administration will put the needed brakes on an irresponsibleprofession.Below, we repost his recent critique within a series published inPsychiatric Times. An excerpt from his comprehensive overall critique of theDSM5-- Opening Pandora's Box: The 19 Worst Suggestions For DSM5--is postedon our website at: http://www.ahrp.org/cms/content/view/682/9/The complete text is at:http://www.psychiatrictimes.com/print/article/10168/1522341Contact: Vera Hassner Sharavveracare212-595-8974~~~~~~http://www.psychiatrictimes.com/display/article/10168/1541615 Psychiatric Times DSM5 and "Psychosis Risk Syndrome:" Not Ready For Prime Time By Allen Frances, MD March 19, 2010 Among all the problematic suggestions for DSM5, the proposal for a"Psychosis Risk Syndrome" stands out as the most ill--conceived andpotentially harmful. It aims to solve a pressing problem in psychiatry-- theneed for early identification and preventive treatment. Psychotic episodescreate tremendous short-term impairment and may impact negatively onlong-term prognosis and treatment efficacy. It would save great suffering ifwe could get there early and do something useful to reduce the lifetimeburden of illness before too much damage is done. But good intentions are not enough. The whole concept of earlyintervention rests on 3 fundamental pillars-- being able to diagnose theright people and then providing them with a treatment that is effective andsafe. "Psychosis Risk Syndrome" fails badly on all 3 counts: 1. It would misidentify many teenagers who are not really at riskfor psychosis. 2. The treatment they would most often receive (atypicalantipsychotic medication) has no proven efficacy, but. . . 3. It does have definite dangerous complications. First, let's deal with the misidentification problem. Even in themost expert of hands (ie, in very highly selected research clinic settings),at least 2 of 3 people who get the diagnosis do not go on to becomepsychotic. Of great counterintuitive interest, the longer the researchclinic operates, the lower its rate of correct identification becomes. Withtime and spreading reputation, the clinic attracts increasinglyheterogeneous referrals-- so that it is more difficult to discriminate fromamong them those who are truly at risk for psychosis. What would be the misidentification rate once the diagnosis becameofficial and was applied in the real world? No one can say for sure, buttwo-thirds is certainly a lower limit of misidentification. There areseveral reasons to believe that the ratio of wrong diagnoses would actuallybe much higher: o The raters in general practice would be much less expert thanspecialists in research clinics o The "patients" would be closer to normal and harder todiscriminate o Drug company marketing would influence parents and cliniciansto be especially alert to any strangeness in teenagers. It has been estimated that the false-positive rate would jump fromabout 70% in specialty clinics to about 90% in general practice. This meansthat as many as an astounding 9 in 10 individuals identified as "risksyndrome" would not really be at risk for developing psychosis. Those supporting the diagnosis for DSM5 have attempted to fix thisoverwhelming problem by inserting a definitional criterion that the personmust be seeking treatment. They hope this requirement would both reduce therate of false-positives and ensure that those who are misidentified willneed some form of treatment. Their preferred treatment for "risk syndrome"is cognitive/behavior therapy which might be helpful (and is unlikely to beharmful)-- even for those who have been misidentified. This fix fails badly on both counts-- ie, in reducingfalse-positives and in guaranteeing safe treatment. Under the best ofcircumstances, the overwhelming majority of "treatment seekers" will stillbe false-positive. Once the diagnosis is official and marketed, the problemwill get much worse as a new army of "treatment seekers" is brought in byfamily members. Their perceived "strangeness" may come from many causesother than psychotic risk, including drug use; adolescent developmentalissues and rebelliousness; culturally dystonic creativity; stableschizotypal personality; or normal eccentricity. A far more efficient signalto noise filter would have been to require that the individual must alsohave a close family member who has experienced psychotic episodes. Then we get to the worrying treatment issues. It is the height ofunrealistic wishful thinking to assume that most of the misidentifiedpatients will get cognitve therapy. Cognitive therapy is in short supply andlargely unavailable--especially for this population. On the other hand,antipsychotic medications are fairly ubiquitous and already frequently givenfor off-label indications-- particularly to kids on Medicaid. It has not yetbeen established that antipsychotic medications are effective in preventingpsychotic episodes or in improving the life course in those who would meetthe criteria for "risk syndrome." This is an area that to date has receivedlittle study and the few existing findings are equivocal. In contrast, the harmful effects of atypical antipsychotics areextremely well established and frightening. Teenagers starting at an averageweight of 110 pounds gained an average of 12 pounds in 12 weeks-- and one ofthe antipsychotics caused an 18-pound weight gain in this period. Thisraises the risk for diabetes, metabolic syndrome, and a shorter life span. To sum up: 1. The "risk syndrome" would misidentify many (somewhere between3 and 9) kids for every one correctly identified 2. The treatment most likely to be offered has no provenefficacy, but can have extremely dangerous complications. This is a clearly the prescription for an iatrogenic public healthdisaster. The goal of early identification and proactive treatment inpsychiatry is laudable-- but elusive and not currently attainable.Prevention requires having a happy combination of accurate identificationand effective and safe treament. Instead, we now have the opposite dangerouscombination-- wildly inaccurate identification with a likely ineffective butdefinitely risky treatment. The people who developed the "risk syndrome" suggestion for DSM5 aresmart and have no conflict of interest motivation. How can they be promotingsuch a bad idea? The answer is that, like most experts, they have a blindspot when it comes to understanding the huge gulf between the real world andtheir rarified research experience. Perhaps in their hands, thefalse-positive rate can be kept to 2 out of 3 and the cognitve treatmentsgiven will be safe and generally helpful. It has been difficult for them toappreciate just how differently and destructively their pet suggestion wouldplay were it to become prematurely official. "Psychosis Risk Syndrome" belongs in the DSM appendix reserved fornew diagnoses that deserve further study-- but that are not ready for primetime. [Editor's note: This commentary also appears on the website ofPsychology Today <> .]FAIR USE NOTICE: This may contain copyrighted (C ) material the use of whichhas not always been specifically authorized by the copyright owner. Suchmaterial is made available for educational purposes, to advanceunderstanding of human rights, democracy, scientific, moral, ethical, andsocial justice issues, etc. It is believed that this constitutes a 'fairuse' of any such copyrighted material as provided for in Title 17 U.S.C.section 107 of the US Copyright Law. This material is distributed withoutprofit. =====In accordance with Title 17 U.S.C. 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